Long Term Case Assistance Request
Requestor Information
Name
*
First Name
Last Name
Agency
*
Phone Number
*
-
Area Code
Phone Number
E-mail
*
Supervisor Number
*
-
Area Code
Phone Number
Supervisor Name
*
First Name
Last Name
Case Information
Case Number
Case #
Gang
Drug
# of Targets
# of Buys
Pens
Wires
Confirm
Clear
Should be Empty: